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Copy CPPT

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Catatan

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No.Rekam Medik

Nama Pasien

TTL

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Formulir CPPT

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Profesi

Nama Pengisi Data

S [SUBJECTIVE]

O [OBJECTIVE]

<p>USG ABDOMEN</p>

<p>- USG yang ditemukan sesuai dengan pemeriksaan.</p>

<p>- Kelainan yang ditemukan :</p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><strong><u><span style="font-size:12.0pt">Kandung empedu</span></u></strong><span style="font-size:12.0pt"> : </span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><span style="font-size:12.0pt">Besar normal, <em>dinding </em></span><em><span style="font-size:12.0pt">menebal iregular. </span></em><span style="font-size:12.0pt">Duktus biliaris intr</span><span style="font-size:12.0pt">a </span><span style="font-size:12.0pt">hepatal t</span><span style="font-size:12.0pt">id</span><span style="font-size:12.0pt">ak melebar,</span><span style="font-size:12.0pt">  tidak </span><span style="font-size:12.0pt">tampak </span><span style="font-size:12.0pt">lesi</span><span style="font-size:12.0pt"> hiperekhoik dengan<em> acoustic shadow</em></span><em><span style="font-size:12.0pt"> intraluminal</span></em><em><span style="font-size:12.0pt">.</span></em><em> </em><em><span style="font-size:12.0pt">Tampak sludge intraluminal.</span></em></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><strong><u><span style="font-size:12.0pt">Ginjal kiri</span></u></strong><strong> </strong><span style="font-size:12.0pt">:</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><span style="font-size:12.0pt">Ukuran normal</span><span style="font-size:12.0pt">, kontur normal, parenkim normal, inte</span><span style="font-size:12.0pt">n</span><span style="font-size:12.0pt">sitas gema</span><span style="font-size:12.0pt"> masih normal</span><span style="font-size:12.0pt">. Batas tekstur parenkim dengan central echocomplek </span><span style="font-size:12.0pt">masih jelas</span><span style="font-size:12.0pt">. <em>Tampak </em></span><em><span style="font-size:12.0pt">lesi</span></em><em><span style="font-size:12.0pt"> hiperekhoik</span></em><em><span style="font-size:12.0pt"> multipel</span></em><em> </em><em><span style="font-size:12.0pt">dengan acoustic shadow</span></em><em><span style="font-size:12.0pt"> di pole tengah dengan diameter terbesar  lk 0,8 cm.</span></em> <span style="font-size:12.0pt">Sistem pelvokalises tidak melebar. </span><span style="font-size:12.0pt">U</span><span style="font-size:12.0pt">reter tidak terdeteksi.</span></span></span></p>

A [ANALISIS]

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><strong><em><u><span style="font-size:12.0pt">Kesan </span></u></em></strong><u><span style="font-size:12.0pt">: </span></u></span></span></p>

<ul>
	<li style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><strong><em><span style="font-size:12.0pt">Cholecystitis dengan sludge GB</span></em></strong></span></span></li>
	<li style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><strong><em><span style="font-size:12.0pt">Nephrolithiasis multipel sinistra</span></em></strong></span></span></li>
	<li style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><strong><em><span style="font-size:12.0pt">USG hepar, spleen, pancreas, ginjal kanan dan</span></em></strong><strong><em> </em></strong><strong><em><span style="font-size:12.0pt">vesika urinaria </span></em></strong><strong><em><span style="font-size:12.0pt">saat ini tak tampak kelainan</span></em></strong><strong><em><span style="font-size:12.0pt">.</span></em></strong></span></span></li>
</ul>

P [PLANNING]

I [INSTRUKSI]